Rhabdomyolysis: How to Avoid This Serious Weekend Warrior Condition

New to spinning? Diving headfirst into a half-marathon with little training? Sit all week and then jump into all-out exercise on the weekends? Then there’s a 12-letter word that needs to be on your radar: rhabdomyolysis.

Often referred to as “rhabdo,” this serious syndrome can occur by overtraining beyond your body’s current ability. And although considered rare and more often associated with “crush” injuries like car accidents and building collapses, reports of kidney-damaging rhabdo after a single spinning class are gaining the attention of medical researchers and the media alike.

A study featuring case reports of spinners developing exertional rhabdomyolysis, many after taking their first class, highlights the fact that going too hard too fast can lead to serious side effects. This is especially true for a subset of people who are often beginners and/or out of shape. Reports show that active-duty soldiers, firefighters and others with particularly taxing professions and training protocols face a risk of rhabdomyolysis; research also suggests that CrossFit workouts, running and P90X are other among other reasons people land in the hospital for rhabdomyolysis. (1, 2)

In fact, the rhabdomyolysis-CrossFit connection is actually celebrated with an infamous “uncle rhabdo” cartoon that features an exhausted, overtrained clown hooked up to a dialysis machine. (3, 4) You do not have to push to the point of rhabdo to get incredible fitness results.

Now, in no way to do I want to deter you from working out. Quite the opposite, given the incredible (and sometimes even surprising) benefits of exercise, including high-intensity interval training HIIT workouts. But this does warrant some simple precautions to take to avoid this kidney-damaging ailment. And, of course, don’t push too hard too fast when you’re starting a new workout routine.

What Is Rhabdomyolysis?

Rhabdomyolysis: A Brief History

When it comes to the history of rhabdomyolysis, it appears the condition was first described in the Bible’s Book of Numbers in the Old Testament. In this instance, the Jews suffered a “plague” while consuming large amounts of quail during the exodus from Egypt. The belief is that the quails ingested poisonous hemlock, which triggered rhabdomyolysis in the humans feasting on the game bird. (5)

But it wasn’t until doctors published literature on “crush syndrome” that we started to really understand the link between muscle damage and acute kidney damage. This research was the result of understanding how World War II-era bombing in London crushed victims’ muscles and triggered acute kidney damage. Today, we know rhabdomyolysis is major cause of acute-onset kidney failure. (6)

Rhabdomyolysis Pathophysiology

What is rhabdo in medical terms? It’s a complex condition involving the rapid breakdown of skeletal muscle that causes muscle proteins and other muscle constituents to leak outside of cells and into the bloodstream. This leakage includes:

Myoglobin (The term myoglobinuria refers to myoglobin present in urine.)

Creatine kinase (CK)

Aldolase

Lactate dehydrogenase

Electrolytes

A rise in free ionized calcium inside cells is a classic trait of the syndrome. Researchers say this can be triggered by:

Energy depletion

Direct plasma membrane rupture

This increase in cell calcium levels sets off a series of cellular side effects, including mitochondrial dysfunction and abnormal reactive oxygen species. Ultimately, this results in muscle cell death.

Doctors use a combination of clinical symptoms plus tests to look for myoglobin and excess creatine phosphokinase (CK) levels to diagnose the serious syndrome. (7)

Rhabdomyolysis can cause a wide range of impacts on your body. On one end of the spectrum, someone may experience no symptoms of illness but have elevated creatine kinase levels. On the other hand, some people experience life-threatening symptoms linked to extreme elevations in creatine kinase, electrolyte imbalance, acute renal failure and disseminated intravascular coagulation. (8)

Is rhabdomyolysis permanent? While overtraining beyond one’s capability is one common cause of exercise-induced rhabdomyolysis, there are actually more than 100 different triggers. It’s also possible to experience rhabdo with or without acute renal failure. Quick identification and treatment can often eradicate long-term problems, although recovering may take several weeks even in cases of severe muscle weakness without kidney damage.

Rhabdomyolysis Risk Factors and Causes

Anyone taking up exercise for the first time or training hard outside in the heat should take extra precaution to understand the risk factors, causes and symptoms of rhabdomyolysis.

The condition impacts roughly 26,000 people a year in the U.S., although many experts believe it’s much higher than that, with milder, more asymptomatic cases unreported. (11)

While some people show no symptoms and simply have elevated creatine kinase levels, others experience life-threatening complications like cardiac arrest, arrhythmias, compartment syndrome, disseminated intravascular clotting and acute kidney damage.

Risk Factors of Exertional Rhabdo

The following can increase your risk of suffering from exertional rhabdomyolysis: (12, 13)

Overtraining, especially when you’re de-conditioned, training beyond your ability too fast or returning to heavy workouts after time off (examples: after an injury, vacation or winter/spring break)

Strenuous workouts in hot, humid weather

Training in full gear (think two-a-day football practices with full pads and helmets or firefighters in full-gear trainings)

Being a large football player — the National Academy of Sports Medicine points out a study identifying the sweat rates of certain football players, and sweat rates in large lineman can hit 3.9 liters an hour and up to 14 liters per day. Due to high intensity activity and abundant fluid loss, football players run a high risk of dehydration and subsequent exertional rhabdomyolysis (14)

Performing exercise to muscle failure during the eccentric phase — an example of this would be the quadriceps eccentrically lengthening during the downward phase of a squat

Exercise isn’t the only cause of rhabdo. In fact, rhabdomyolysis and statins drugs are linked. Other rhabdomyolysis risk factors include:

Certain prescription and illegal drugs (see the list of drugs that could contribute to the development of rhabdo)

Heavy alcohol or drug use

Prolonged bed rest

Causes

How do you get rhabdomyolysis? In the case of the spinning-rhabdo cases we highlighted earlier, the culprit is overtraining that leads to catastrophic muscle breakdown. This is known as exertional rhabdomyolysis.

A study published in the American Family Physician lists the following as physical causes of rhabdo: (15)

Some cases arise from genetic conditions that lead to metabolism issues related to fats, carbohydrates or purine-rich foods.

Rhabdomyolysis Complications

According to John Sauret, MD, rhabdomyolysis complications can be broken down into “early” and “late” categories.

Early complications

Hyperkalemia

Hypocalcemia

Hepatic inflammation

Cardiac arrhythmia

Cardiac arrest

Late complications

Acute renal failure

Disseminated intravascular coagulation

Early or late complication

Compartment syndrome

Symptoms of Rhabdomyolysis

According to Merriam-Webster, the rhabdomyolysis definition is: “The destruction or degeneration of muscle tissue (as from traumatic injury, excessive exertion, or stroke) accompanied by the release of breakdown products into the bloodstream and sometimes leading to acute renal failure.” (16)

But the exact symptoms one experiences sometimes depend on the causes of rhabdo. Still, here are some of the hallmark signs of the condition. Note: Not all symptoms are always present in each case of rhabdomyolysis.

How to Avoid Rhabdomyolysis, AKA ‘Rhabdo’

When a rhabdomyolysis diagnosis is suspected, the main focus is to avoid damage to the kidneys. Patients tend to have much better outcomes when the syndrome is identified and properly treated fast. Rhabdomyolysis treatment involves:

Conventional Treatment

Large quantities of IV fluids

Dialysis, if necessary

Once urine starts flowing again, doctors routinely use sodium bicarbonate and mannitol. Even though these are commonly used, they are poorly supported by the latest evidence.

Rhabdomyolysis recovery, including getting over muscle tenderness and weakness, can last several weeks, even in milder cases. The same goes for a trainer taking on a new fitness client. Mild cases of this syndrome do not require medical treatment and recovery time is usually about a week.

Rhabdomyolysis Prevention Tactics

Avoid strenuous workouts in hot, humid weather unless you are acclimated to do so.

When working out, drink water and use electrolyte replacement fluids for workouts lasting more than an hour or workouts in very hot weather.

If you’re in the market for a personal trainer, make sure the trainer understands rhabdo. I suggest looking for trainers with at least a bachelor’s degree in exercise science and with certifications from organizations like the National Academy of Sports Medicine (NASM), National Strength and Conditioning Association (NSCA) or the American College of Sports Medicine (ACSM).

Coaches should not start a training season using strenuous, repetitive exercises the trainees aren’t used to.

Rhabdomyolysis Precautions

Rhabdomyolysis symptoms warrant an ER visit and should be taken seriously. Even those presenting symptoms without cola-colored “brown pee” could be suffering from rhabdo.

The good news is quick identification and treatment (usually involving higher levels of IV fluids) can often bring the body back into balance without long-term damage.

Rhabdo complications can be very serious and sometimes fatal, though, so proper prevention and identification of the symptoms is important. More common “early” complications involve severe hyperkalemia, which can trigger cardiac arrest. Acute renal failure is considered the most serious “late” complication. It occurs in about 15 percent of rhabdo patients.

Final Thoughts on Rhabdomyolysis or ‘Rhabdo’

Rhabdomyolysis, also known as “rhabdo,” is a life-threatening, sometimes fatal condition that requires immediate medical attention.

Rhabdomyolysis is the result of catastrophic muscle damage that can result from a number of factors, including but not limited to drug and alcohol abuse, statin medications, overtraining, heat stress, dehydration, snake bites, prolonged bed rest, infections, and metabolic and endocrine issues.

When overtraining triggers rhabo, it’s known as exertional or exercise-induced rhabdomyolysis.

Diagnosing the condition usually involves a doctor taking clinical symptoms into account, recent events and lab work to look for elevated CK levels and the presence of myoglobin from major muscle breakdown.

Standard treatment partially depends on the cause and severity of the syndrome, but large amounts of intravenous fluids are generally included in treatment.

There are many ways to prevent this condition, including proper hydration, electrolyte drinks, avoiding training in full gear in hot, humid weather, easing into exercise and getting your CK levels checked when you’re on statin drugs.

If you anticipate more strenuous exercise, weigh yourself just before you start workout out and right after. Make sure you replace any lost fluids with electrolyte-rich drinks.

Although dehydration and heat stress can contribute to the syndrome, rhabdo can develop in the absence of these two things, too.

Get FREE Access!

Dr. Josh Axe is on a mission to provide you and your family with the highest quality nutrition tips and healthy recipes in the world...Sign up to get VIP access to his eBooks and valuable weekly health tips for FREE!

12 Comments

This is called Azatoria in horses. It ocurred when they used to be used to farm. In the winter they weren’t working hard daily.Then, start of plowing season, if they weren’t started slow their muscles would “tie up”. Accute symptoms were also dark urine and kidney damage.
Just an interesting topic I have not read about pertaining to humans before.
Thank you for all the interesting articles!!

This is a really interesting article for me at 88, I put the symptoms I am suddenly experiencing down to old age i.e. weakness, loss of muscle tone, muddled thinking, & dark brown urine.
Perhaps it may indicate I am experiencing signs of rhabo? I do have and always have had a problem with keeplng up my liaquid levels, can go all day without taking a drink of anything.
I would be very interested in your opinion.

The biggest with spinning is the lack of air flow over your body. I’ve been riding indoors on rollers long before the word ‘spinning’ was used. You need a strong fan blowing on you to help your body cool off, otherwise you will overheat very quickly.

Really good information, but please differentiate between personal fitness trainers & athletic trainers, which as I’m sure you know are 2 totally different careers with varying levels of educational requirements & responsibilities & duties. A lot of people in the general public have no clue that they are different. Thanks!

Great Article. I was diagnosed with Rhabdo in July after doing a strenuous workout in the heat and It’s the worst thing Ive ever gone through in my life. Ive seen Four doctors, 3 misdiagnosed with me with heat exhaustion over a five week period. All said I was dehydrated. Two E.R Visits with no fluids administered. They told me my CK levels were still at 1000 5 weeks in and now Im in debt almost $5k with no treatment and I feel like I’m dying. This is rough…

Thank you for this interesting information. Also interesting is that the Bible reference is from the book of numbers. You may want to repeat your count of the letters in the word (as mentioned in your opening paragraph). :-)